S90.119 Contusion of unspecified great toe without damage to nail

Name of the Condition

• Contusion of unspecified great toe without damage to nail

Summary

A contusion of the great toe is a bruise resulting from blunt force trauma that damages underlying soft tissues without breaking the skin or affecting the nail. It typically causes localized pain, swelling, and discoloration in the toe area.

Causes

Direct impact or trauma to the great toe, such as stubbing it against a hard object or dropping a heavy item on the toe. Sports injuries or accidents involving the foot may also lead to this condition.

Risk Factors

• Participation in activities with a high risk of toe trauma, such as running or contact sports.
• Wearing open-toed or poorly fitting footwear that exposes the toe to injury.
• Occupations involving physical labor or environments where foot injuries are more likely.

Symptoms

• Pain and tenderness around the affected great toe.
• Localized swelling and discoloration (bruising) of the skin.
• Possible difficulty walking or applying pressure on the toe.

Diagnosis

Physical examination by a healthcare provider to assess tenderness, swelling, and discoloration. A review of the patient’s history to determine the mechanism of injury. Imaging (e.g., X-rays) may be used to rule out fractures or other injuries.

Treatment Options

• Resting the affected toe to avoid further injury.
• Applying ice to reduce pain and swelling.
• Elevating the foot to minimize swelling.
• Over-the-counter pain relievers for discomfort.
• Wearing protective footwear to prevent additional trauma.

Prognosis and Follow-Up

Most contusions heal within 1–2 weeks with proper care. Follow-up may be recommended if symptoms worsen or persist, or if there is uncertainty about the injury. Monitoring for signs of infection or complications is important during recovery.

Complications

• Persistent pain or swelling beyond the expected healing time.
• Development of a hematoma (blood collection under the skin).
• Rarely, infection if the skin is broken (though this code specifies no nail damage).

Lifestyle & Prevention

• Wear closed-toe, well-fitting shoes during activities with a risk of toe injury.
• Use protective gear (e.g., toe guards) in sports or work environments where foot trauma is common.
• Avoid walking barefoot in areas with hard or uneven surfaces.

When to Seek Professional Help

Seek medical attention if there is severe pain, inability to bear weight, signs of infection (e.g., redness, pus), or if the toe appears deformed, as these may indicate a more serious injury like a fracture.

Tips for Medical Coders

This code (S90.119) is used for a contusion of the great toe without nail damage, where the specific toe is not identified. Documentation should clearly state the absence of nail injury and the lack of specification for the toe. Ensure the encounter type (e.g., initial, subsequent) is documented separately if applicable, as this code does not include encounter details.